Varices and variceal bleed resident survival guide

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Twinkle Singh, M.B.B.S. [2], Rim Halaby, M.D. [3]

Overview

Gastroesophageal varices are portosystemic collaterals resulting from portal hypertension which is a complication of cirrhosis. Gastroesophageal varices are prone to rupture leading to life threatening hemorrhage.

Causes

Life Threatening Causes

Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated. Variceal bleed is a life-threatening condition and must be treated as such irrespective of the causes.

Common Causes

• Cirrhosis

Screening and Management of Non Bleeding Varices in Cirrhosis

❑ Diagnosis of cirrhosis ❑ No evidence of variceal bleed

Screen for varices: ❑ Order an Esophagogastroduodenoscopy (EGD)

No varices

Presence of varices

Follow up with EGD: ❑ Every 3 years ❑ At the time of any hepatic decompensation, and annually thereafter

Small (<5mm)

Medium/Large (>5mm)

❑ Assess risk of hemorrhage

❑ Assess risk of hemorrhage

High†

Low‡

High†

Low‡

❑ Propranolol (starting dose: 20mg), orally, twice per day, OR ❑ Nadolol (starting dose: 40mg), orally, once per day

❑ Propranolol (starting dose: 20mg), orally, twice per day, OR ❑ Nadolol (starting dose: 40mg), orally, once per day, OR ❑ EGD every 2 years if beta blockers are not used

❑ Propranolol (starting dose: 20mg), orally, twice per day, OR ❑ Nadolol (starting dose: 40mg), orally, once per day, OR ❑ Endoscopic variceal ligation

First line: ❑ Propranolol (starting dose: 20mg), orally, twice per day, OR ❑ Nadolol (starting dose: 40mg), orally, once per day Second line: Endoscopic variceal ligation

If a patient is treated with endoscopic variceal ligation: ❑ Repeat endoscopic variceal ligation every 1-2 weeks until obliteration ❑ Perform a first surveillance EGD 1-3 months after obliteration ❑ Repeat endoscopic variceal ligation every 6-12 months to check for variceal recurrence

The algorithm is based on the practice guidelines approved by American Association for the Study of Liver Diseases (AASLD) and American College of Gastroenterology (ACG).

† Varices at high risk of bleeding:

• Cirrhosis with Child-Pugh class B or C severity.
• Presence of red wale marks on varices visualized on endoscopy.

‡ Varices not at high risk of bleeding:

• Cirrhosis with Child-Pugh class A severity.
• No red wale marks on varices.

Management of Actively Bleeding Varices

Suspected acute variceal hemorrhage ❑ Patient with known cirrhosis ❑ Coffee ground emesis

General measures: ❑ Admit the patient to ICU ❑ Assess airway ❑ Obtain peripheral venous access ❑ Blood volume resuscitation (maintain a hemoglobin of 8mg/dl) ❑ Elective or emergent tracheal intubation prior to endoscopy ( mainly in case of concomitant hepatic encephalopathy)

Short term prophylactic antibiotics (7 days) ❑ Oral norfloxacin (400mg twice daily), OR ❑ IV ciprofloxacin (impossible oral administration) ❑ IV ceftriaxone (1g/day) in advanced cirrhosis and in a setting with high prevalence of quinolone resistance

Initiate pharmacological therapy when variceal bleed is suspected, even before confirming the diagnosis by EGD: ❑ Vasopressin (IV infusion 0.2 to 0.4 units/min up to 0.8 units/min)+ Nitroglycerine (IV 40 μg/min, can be increased up to 400 μg/min) adjusted to maintain a systolic blood pressure 90 mmHg, OR ❑ Terlipressin (IV 2 mg every 4 hours titrated down to 1 mg every 4 hours)- not available in US- OR ❑ Somatostatin (250 μg IV bolus followed by 250 μg/hr continuous infusion) OR ❑ Octreotide (somatostatin analogue), IV bolus of 50μg followed by continuous infusion 50μg/hour ❑ Continue pharmacological therapy 3-5 days after the diagnosis is confirmed

Perform EGD: ❑ Confirm the diagnosis of variceal bleed (within 12 hours of admission) ASAP

Esophageal varices or gastric varices in the lesser curvature

Gastric varices in the fundus

Perform endoscopic therapy: ❑ Endoscopic variceal ligation (preferred) ❑ Sclerotherapy (if endoscopic variceal ligation is not feasible)

Perform endoscopic therapy: ❑ Endoscopic variceal obturation with tissue adhesive such as N-butyl-cyanoacrylate, isobutyl-2-cyanoacrylate, or thrombin

Failure to control OR recurrence of variceal bleed despite pharmacological and endoscopic therapy?

Failure to control OR recurrence of variceal bleed despite pharmacological and endoscopic therapy?

Yes ❑ TIPS, OR ❑ Shunt surgery

No Management following recovery of the patient: ❑ Secondary prophylaxis before discharge (non selective beta blocker + endoscopic variceal ligation)

Yes ❑ TIPS

No secondary prophylaxis

❑ Refer transplant candidates to a transplant center

The algorithm is based on the practice guidelines approved by American Association for the Study of Liver Diseases (AASLD) and American College of Gastroenterology (ACG).

Do's

• Use either propranolol or nadolol when non selective beta blockers are indicated.
• If a patient is placed on beta blocker, its dose should be adjusted to the maximum tolerated dose.
• When endoscopic variceal ligation (EVL) is done, repeat EVL every 1 to 2 weeks until complete obliteration of varices. Follow up with EGD after 1 to 3 months and every 6 to 12 months thereafter to screen for varices recurrence.
• Vasoconstrictive pharmacotherapy should be initiated as soon as variceal bleeding is suspected and should be continued for 3 to 5 days after the diagnosis of bleeding varices is established.

Dont's

• In patients with small varices, who are on beta blockers, follow up with EGD is not recommended.
• Beta blockers are not recommended to prevent variceal development in cirrhotic patients with no varices.
• Nitrates, sclerotherapy and shunt therapy should not be used to prevent first variceal bleed.
• Don't use beta blockers in acute bleed because it will cause reflex tachycardia that might worsen bleeding.
• Consider transfusion of FFP and platelets in patients with significant coagulopathy and/or thrombocytopenia.
• Don't provide excessive resuscitation with saline solution in variceal bleed.